Midurethral Sling Surgery Research Articles

Postoperative Utilization of Opioids After Midurethral Sling Surgery: A Prospective Clinical Practice Study.

This study was performed to understand opioid consumption after midurethral sling (MUS) procedures to provide surgeons with guidelines on appropriate prescription regimens. This study aimed to evaluate postdischarge narcotic use (PDNU) after MUS surgery using a restrictive postdischarge opioid regimen. This prospective clinical practice study included women undergoing MUS surgery from December 2018 to October 2019. Patients were discharged with an electronic prescription for 5 tablets of an oral narcotic. Brief Pain Inventory (BPI) surveys were collected preoperatively. Patients answered questions regarding remaining number of opioid tablets, BPI scores, and patient satisfaction on day 1, week 1 (postoperative week [POW] 1), and 4-6 weeks (POW4-6) postoperatively. Electronic records were reviewed to determine narcotic refills. Primary outcome was PDNU measured in morphine milligram equivalents (MME). Secondary outcomes evaluated refill rate, BPI scores, and patient satisfaction. Standard statistical tests were applied. Fifty-six patients were included in the analysis. Total median (interquartile range) PDNU was 12.5 (0-37.5) MME at POW1 and 15.0 (0-37.5) MME at POW4-6, which is approximately equivalent to 2 oxycodone (5 mg) tablets. Eighteen patients (32.1%) took 0 narcotics postdischarge. Brief Pain Inventory scores showed that "worst pain" was highest on postoperative day 1 with a median (interquartile range) score of 6 (4-8). At the POW1 and POW4-6 mark, 94.3% and 92% of patients, respectively, were satisfied or extremely satisfied with their pain control. Seven patients (11.8%) required a refill. Most patients undergoing MUS surgery used no more than 2 oxycodone (5 mg) tablets during their 6-week postoperative course, with almost a third not requiring any narcotics. Low pain scores and high patient satisfaction rates were noted.

Cost-effectiveness of prophylactic retropubic sling at the time of vaginal prolapse surgery

Prophylactic midurethral sling placement at the time of prolapse repair significantly reduces the risk for de novo stress urinary incontinence, but it is associated with some small but significant morbidities. Because there has not been a standardized approach to midurethral sling utilization, decision analysis provides a method to evaluate the cost and effectiveness associated with varying midurethral sling placement strategies in addressing the risk for de novo stress urinary incontinence. We aimed to compare the cost effectiveness of the 3 midurethral sling utilization strategies in treating de novo stress urinary incontinence 1 year after vaginal prolapse repair. The 3 approaches are (1) staged strategy in which prolapse repair is done without prophylactic midurethral sling placement, (2) universal sling placement in which prolapse repair is accompanied by prophylactic midurethral sling placement, and (3) selective sling placement in which prolapse repair is accompanied by prophylactic midurethral sling placement only in patients with a positive prolapse-reduced cough stress test. We created a decision analysis model to compare staged strategy, universal sling placement, and selective sling placement. We modeled probabilities of de novo stress urinary incontinence, patients choosing subsequent midurethral sling surgery for de novo stress urinary incontinence, and outcomes related to midurethral sling placement. De novo stress urinary incontinence rates were determined for each strategy from published data. The likelihood of patients with de novo stress urinary incontinence choosing midurethral sling surgery as their first-line treatment was also determined from the literature, and this scenario was only applied to patients without prophylactic midurethral sling placement at their index prolapse repair. Finally, outcomes related to midurethral sling placement, including recurrent or persistent stress urinary incontinence, voiding dysfunction requiring sling lysis, mesh exposure requiring excision, and de novo overactive bladder requiring medications, were all derived from publicly available data. All midurethral sling placement procedures were assumed to be retropubic. The costs for each procedure were obtained from the 2020 Centers for Medicare & Medicaid Services Physician Fee Schedule or from previous literature with convertion to 2020 equivalent US dollar prices using the Consumer Price Index. The primary outcome was modeled as the incremental cost-effectiveness ratio. We performed multiple 1-way sensitivity analyses to assess model robustness. The lowest-cost strategy was the staged strategy, which cost $1051.70 per patient, followed by $1093.75 for selective sling placement and $1125.54 for universal sling placement. The selective sling approach, however, had the highest health utility value; therefore, universal sling placement was dominated by selective sling placement because it is both less costly and more effective. When compared with the staged strategy, selective sling placement was cost effective with an incremental cost-effectiveness ratio of $2664 per quality adjusted life-years, meeting the predetermined threshold. In multiple 1-way sensitivity analyses, the variable with the largest effect was the percentage of patients electing to undergo subsequent midurethral sling surgery for de novo stress urinary incontinence after the index surgery. Only when this proportion exceeded 62% did universal sling placement become the cost-effective option because selective sling placement surpassed the predetermined incremental cost-effectiveness ratio threshold and became dominated. Selective sling placement was the preferred and cost-effective strategy in treating de novo stress urinary incontinence 1 year after vaginal prolapse repair. Surgeons should counsel their patients preoperatively regarding the possibility of de novo stress urinary incontinence after prolapse repair, as well as on the benefits and risks of prophylactic midurethral sling placement surgery.

Sexual Function Following Treatment for Stress Urinary Incontinence With Bulk Injection Therapy and Mid-Urethral Sling Surgery

Peri-urethral bulking injections (PBI) gain popularity for the treatment of stress urinary incontinence (SUI), but - in contrast to mid-urethral sling (MUS) surgery - little is known about its impact on sexual function. This was a secondary analysis of a prospective cohort study that included patients with moderate to severe SUI undergoing either MUS surgery or PBI with polydimethylsiloxane Urolastic (PDMS-U). The validated Dutch and English version of the 'Pelvic Organ Prolapse and/or Urinary Incontinence Sexual Function Questionnaire - IUGA Revised' (PISQ-IR) was used to assess sexual function at baseline, at 6 and 12 months of follow-up. For between-group analysis, differences in baseline characteristics were corrected using multivariate analysis of covariance. The primary outcome was the PISQ-IR single summary score of sexually active (SA) women following both procedures, calculated by mean calculation. Secondary outcomes were the PISQ-IR subscale scores of SA and non-sexually active (NSA) women, the proportions of sexual activity and subjective improvement ('Patient Global Impression of Improvement' (PGI-I)). A total of 259 women (MUS: n = 146, PBI: n = 113) were included in this study. The PISQ-IR single summary score of SA women improved following both interventions (in the MUS group from 3.2 to 3.4 and in the PBI group from 3.0 to 3.3 after 12 months). After correcting for differences in baseline characteristics, the PISQ-IR summary score at 6 and 12 months was similar for both treatment groups. For SA women, condition-specific and condition-impact subscale scores significantly improved following both procedures. In treating SUI, PBI is inferior to MUS surgery. However, there is a need for less invasive strategies, especially for women who are unfit for surgery or have contraindications. Sexual function improves after PBI using PDMS-U, which is relevant for the counselling of women with SUI about available treatment options. Strength: until this study, there was a lack of knowledge about the effects of PBI on sexual function. Limitation: there may be indication bias as we did not perform a randomized controlled trial. PBI using PMDS-U and MUS surgery for the treatment of SUI improve sexual function equally in SA women, mainly by decreasing the condition's impact on sexual activity and quality.

Prophylactic antibiotics for preventing infection after continence surgery in women with stress urinary incontinence.

Surgical options for treating stress urinary incontinence (SUI) are usually explored after conservative interventions have failed. Surgeries fall into two categories: traditional techniques (open surgery) and minimally invasive procedures, such as laparoscopic procedures, midurethral sling and injections with urethral bulking agents. Postsurgery infections, such as infections of the surgical site or urinary tract, are common complications. To minimise the risk of postoperative bacterial infections, prophylactic antibiotics may be given before or during surgery. OBJECTIVES: To assess the effects of prophylactic antibiotics for preventing infection following continence surgery in women with stress urinary incontinence. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov and WHO ICTRP; and handsearched journals and conference proceedings to 18 March 2021. We also searched the reference lists of relevant articles. We included randomised controlled trials (RCTs) and quasi-RCTs assessing prophylactic antibiotics in women undergoing continence surgery to treat SUI. Two review authors selected potentially eligible trials, extracted data and assessed risk of bias. We expressed results as risk ratios (RR) for dichotomous outcomes and as mean differences (MD) for continuous outcomes, both with 95% confidence intervals (CIs). We assessed the certainty of evidence using the GRADE approach. We identified one quasi-RCT and two RCTs, involving a total of 390 women. One study performed retropubic urethropexy surgery requiring a transverse suprapubic incision, while the other two studies performed midurethral sling surgery. It should be noted that none of the included studies clearly specified the timing of outcome assessment. We are very uncertain whether prophylactic antibiotics (cefazolin) have an effect on surgical site infections (RR 0.56, 95% CI 0.03 to 12.35; 2 studies, 85 women; very low-certainty evidence) or urinary tract infections or bacteriuria (RR 0.84, 95% CI 0.05 to 13.24; 2 studies, 85 women; very low-certainty evidence). The effect of prophylactic antibiotics (cefazolin) on febrile morbidity is also uncertain (RR 0.08, 95% CI 0.00 to 1.29; 2 studies, 85 women; very low-certainty evidence). We are very uncertain whether prophylactic antibiotics (cefazolin) have any effect on mesh exposure (RR 0.32, 95% CI 0.01 to 7.61; 1 study, 59 women; very low-certainty evidence). None of the three included studies described the assessment of adverse events from antibiotic use, sepsis or bacteraemiain their reports. Only limited data are available from the three included studies and, overall, the certainty of evidence was very low. Moreover, the three included studies evaluated different surgical procedures and dosages of antibiotic administration. Thus, there is insufficient evidence to support or refute the use of prophylactic antibiotics to prevent infection following anti-incontinence surgery. In addition, there were no data regarding adverse effects of prophylactic antibiotics. More RCTs are required.

Treatment of idiopathic overactive bladder with botulinum toxin: real-life results and patients' expectations.

Overactive bladder (OAB) is a prevalent syndrome affecting 11% to 16% of the adult population. When first-line pharmacological therapy is not effective, intradetrusorial injections of onabotulinumtoxinA (BTX-A) might have an important role in controlling symptoms. The main aim of this study was to access both the efficacy and safety of intradetrusor injections of 100U BTX-A in real clinical practice, among women with idiopathic OAB (iOAB). Retrospective study, based on clinical diaries in 136 iOAB female patients, with or without urinary incontinence, submitted to BTX-A injections, between 2005 and 2018 in a tertiary university hospital. Positive response was considered only when the patient mentioned she had great improvement after the injection, otherwise, it was considered negative. A positive response was obtained in 90 patients (66%) after the first injection. Women with a positive response after the first treatment had 7.5 times more chances to improve with the second (P = .01). Discontinuation of the therapy after the first injection was neither dependent on the presence of incontinence at baseline (P = .73) nor it was related to age (P = .6). On univariate analyses, none of the parameters evaluated was useful of predicting successful response, although there was a trend in women who had had a previous midurethral sling surgery for stress urinary incontinence, to have a lower chance of having a positive response after the first injection (P = .06).Thirty-nine women (29%) had at least 1 adverse event, urinary tract infection, and straining to void were the most frequent. Women above 65 years old had less risk of developing a urinary tract infection (P = .04). In real clinical practice, BTX-A injection is an effective (66%) and safe treatment, capable of improving quality of life. Moreover, responding to the first injection seems to predict good clinical outcomes in the second treatment. This procedure can be done with minimal restrictions.

Midurethral Sling Removal or Revision in Women with Chronic Pain.

The objectives of this study are (1) to estimate the incidence of midurethral sling revision/removal in women with preexisting pain diagnoses versus those without these diagnoses and (2) to describe associations between numbers and type of pain diagnoses with revision/removal. Women who underwent midurethral sling surgery between 2009 through 2014 were identified in the MarketScan database and tracked and December 31, 2014. Patients with preoperative chronic pain diagnoses (fibromyalgia, endometriosis, irritable bowel, dyspareunia, low back pain, temporomandibular joint syndrome, interstitial cystitis, pelvic/perineal pain) were compared with controls (those without these diagnoses) regarding mesh sling revision/removal. Logistic regression identified variables associated with mesh revision/removal, and survival analysis compared timing of mesh removal/revision. There were 161,459 women who underwent midurethral sling surgery (pain, 83,484; nonpain, 77,975). Pain and nonpain groups differed in age (52.1 vs 53.5 years, P < 0.01) and insurance status (P < 0.01), with the pain group more commonly living in the South or West. Mean follow-up was 42.3 months. Cumulative risk for sling revision/removal was higher in patients with 1 pain diagnosis relative to controls (relative risk, 1.54; 95% confidence interval [CI], 1.41-1.54). Risks increased with increased pain diagnoses (≥4 diagnoses; relative risk, 3.13; 95% CI, 2.81-3.47). Pelvic pain conditions had greatest odds of mesh revision/removal (dyspareunia adjusted odds ratio [aOR], 2.44; 95% CI, 2.23-2.63; interstitial cystitis aOR, 1.46; 95% CI, 1.27-1.66; pelvic/perineal pain aOR, 1.41; 95% CI, 1.33-1.48). Co-occurrence of dyspareunia and interstitial cystitis or pelvic/perineal pain had 12.7% cumulative incidence of sling revision/removal. Cox proportional hazards revealed greatest risk for those with pelvic pain conditions (hazard ratio, 2.40; 95% CI, 2.13-2.70). Chronic pain diagnoses increased risk of midurethral sling revision/removal; pelvic pain and numbers of diagnoses increased this risk.

Listening to Learn: A Qualitative Analysis of Women's Experiences with Mesh Mid-urethral Sling Surgery

ObjectiveTo improve women's experiences with mesh mid-urethral sling (MUS) surgery for treatment of stress urinary incontinence (SUI), we sought to qualitatively examine patient perspectives of MUS surgery, organize resulting patient-derived themes, and present our findings as potential springboards for future research and quality improvement efforts. MethodsWe conducted semi-structured focus groups and interviews of patients who had undergone mesh MUS surgery at a single tertiary referral institution. Discussions were recorded, transcribed, de-identified, and analyzed using deductive and inductive content analysis. Two researchers independently performed line-by-line coding which was verified by two additional researchers. ResultsEleven women participated. Most sought SUI care after becoming frustrated with their symptoms. However, some participants experienced barriers to care or dismissal of their symptoms by their physicians. While participants expected improvements in SUI symptoms after MUS surgery, some expected improvement or resolution of other pelvic floor-related issues such as bowel symptoms. Despite having improved SUI symptoms, participants described non-SUI symptoms as negative outcomes from their MUS surgery. Overall, participants wished SUI-associated embarrassment could be lessened and suggested public service announcements to help normalize discussion of SUI symptoms. ConclusionObtaining first-hand information from SUI patients who have undergone MUS surgery provides insights into what matters to patients. Information from this study can help support further investigation into barriers to care for SUI patients and further study into improving counseling on goals and expectations of MUS surgery. The themes complement the current knowledge on MUS by providing insights that can only be collected through open-ended inquiry.

Establishing the Queensland Pelvic Mesh Service: Preliminary experience.

Transvaginal mesh (TVM) has been used for treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Mesh-related complications are reported in 3% of women receiving mid-urethral sling surgery for SUI and in up to 20% of women who receive TVM for POP. The Australian Senate Enquiry report in March 2018 recommended that each Australian state establish specialist multidisciplinary units for management of TVM complications. The aims of this study are to report on the setting up of the Queensland Pelvic Mesh Service (QPMS) and summarise its first 24months to provide a potential framework for the establishment of similar service models within Australia and internationally. The planning and implementation of QPMS was a complex two-stage co-design process involving clinicians and consumers representing women with TVM complications. Consumer input in planning was important for the optimal establishment of QPMS to meet women's holistic needs. From April 2019 to April 2021, 484 women had been treated by the medical team; 257 women had undergone cystoscopy and examination under anaesthesia; 91 patients had undergone mesh revision surgery - 65 complete excision and 25 partial excision and one sling division; and 180 women had been discharged from QPMS. Providing a comprehensive multidisciplinary service for managing TVM complications requires careful planning with consumer involvement before initiation. Addition of these patients to an existing service may not succeed. Emphasis on surgery may be misplaced for many. QPMS patients, as in sufferers with chronic pain conditions, benefit from psychological support and allied healthcare.

Long-Term Outcomes After Midurethral Mesh Sling Surgery for Stress Urinary Incontinence.

Although midurethral mesh slings are the criterion standard surgical treatment for stress urinary incontinence (SUI), limited data exist regarding long-term outcomes. Thus, our objectives were to evaluate the long-term risk of sling revision and the risk of repeat SUI surgery up to 15 years after the initial sling procedure and to identify predictors of these outcomes. Using a population-based cohort of commercially insured individuals in the United States, we identified women aged 18 years or older who underwent a sling procedure between 2001 and 2018. For sling revision, we evaluated indications (mesh exposure or urinary retention). We estimated the cumulative risks of sling revision and repeat SUI surgery annually using Kaplan-Meier survival curves and evaluated predictors using Cox proportional hazards models. We identified 334,601 mesh sling surgical procedures. For sling revision, the 10-year and 15-year risks were 6.9% (95% confidence interval [CI], 6.7-7.0) and 7.9% (95% CI, 7.5-8.3), with 48.7% of sling revisions associated with mesh exposure. The 10-year and 15-year risks of repeat SUI surgery were 14.5% (95% CI, 14.2-14.8) and 17.9% (95% CI, 17.3-18.6). Women aged 18-29 years had an elevated risk for both sling revision (hazard ratio, 1.20; 95% CI, 1.15-1.25) and repeat SUI surgery (hazard ratio, 1.30; 95% CI, 1.25-1.37) compared with women 70 years and older. In our study population, the 15-year risk of sling revision was 7.9%, with nearly half of revisions due to mesh exposure. These findings provide critical long-term data to support informed decisions for women and health care providers considering midurethral mesh slings.

TU56. LONGITUDINAL ANALYSIS OF TELOMERE LENGTH IN SEXUALLY ASSAULTED WOMEN WITH POSTTRAUMATIC STRESS DISORDER

Mid-urethral sling (MUS) surgeries have revolutionized the management of stress urinary incontinence (SUI). However, MUS is a delicate balance of tension on the mid urethral segment with a 12 % risk of failure to achieve complete continence; and up-to 20 % chance of post-operative voiding dysfunction. We propose a simple technical modification in which the long ends of the tape at suprapubic or groin area are not cut immediately and are covered with a sterile dressing. After 48−72 h post-surgery the patient is checked for continence and voiding difficulties. Following this an ultrasonographic assessment of post-void residual urine is performed. Keeping in mind these 3 criteria the tape is adjusted. After complete subjective as well as objective satisfaction the long ends of tape are cut.This is a retrospective analysis of women who underwent MUS surgery for the management of SUI, with our simple technical modification of tape adjustment in the postoperative period. A total of 17 patients operated by single surgeon in one year were included.Our results show that 58.8 % of our patients who underwent MUS procedures required post-operative tape adjustment. The number was significantly higher in the MUS – Retropubic group (85.7 %) as compared to the MUS – Obturator group (40 %). Three patients in the MUS – Retropubic group required a second time tape adjustment. Following tape adjustment all patients had complete continence (subjective and objective), with no voiding dysfunction.The incidence of postoperative voiding dysfunction is significant following MUS surgery for SUI. A simple technical modification of delaying the cutting of the tape for two to three days gives the opportunity for perfect tension adjustment.

The Evolving Story of Mesh Mid Urethral Slings: The Surgeon's Perspective.

The objective of this study was to obtain the perspectives of surgeons who treat female stress urinary incontinence (SUI) and better understand their range of experiences with mesh mid urethral sling (MUS) surgery. This qualitative study recruited gynecologic and urological surgeons who treat SUI. Surgeons were interviewed by phone and in person using a standardized interview guide. Interviews were transcribed, de-identified, and analyzed by 2 independent researchers. The transcripts were coded and summarized using the principles of thematic analysis. The research team came to consensus that a saturation of ideas representing a diverse demographic of surgeons had been achieved. Twenty-four interviews of surgeons from diverse geographic locations and practice types were performed. Many surgeons described MUS surgery as rewarding and favorably impactful for women with SUI, while others grappled with the serious risks associated with MUS surgery. Those who had treated women with life-altering pain after MUS recounted impactful patient stories. Many stated that recognition, acknowledgement, and appropriate referral of complications were fundamental to responsible and ethical care. Some surgeons expressed frustration and concern about the raised level of controversy and anxiety regarding the MUS landscape. All participants expressed that there was substantial room for improvement in multiple domains. Participants also shared their optimal strategies relevant to MUS surgery. Despite diverse views regarding the role of the MUS, there was agreement among surgeons that the surgeon-patient relationship, thorough informed consent and patient counseling, and accountability are essential when implanting MUSs.

MP19-15 LISTENING TO WOMEN: A QUALITATIVE ANALYSIS OF WOMEN’S EXPERIENCES WITH MESH MID-URETHRAL SLING SURGERY

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making II (MP19)1 Sep 2021MP19-15 LISTENING TO WOMEN: A QUALITATIVE ANALYSIS OF WOMEN’S EXPERIENCES WITH MESH MID-URETHRAL SLING SURGERY Pansy Uberoi, Wai Lee, Kathleen Kobashi, Alvaro Lucioni, Donna Berry, and Una Lee Pansy UberoiPansy Uberoi More articles by this author , Wai LeeWai Lee More articles by this author , Kathleen KobashiKathleen Kobashi More articles by this author , Alvaro LucioniAlvaro Lucioni More articles by this author , Donna BerryDonna Berry More articles by this author , and Una LeeUna Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002004.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Existing stress urinary incontinence (SUI) research focuses on clinical outcomes, which may differ from and overlook key concepts of importance to patients. When patient perspectives are sought, an understanding of what is most important to women is gained. We sought to understand patient experiences including knowledge, attitudes, and beliefs regarding mesh mid-urethral sling (MUS) surgery and outcomes. METHODS: Patients who had undergone placement of a mesh MUS between January 2014 and December 2018 at a single institution by one of three female pelvic medicine and reconstructive surgery (FPMRS) specialists were invited to participate in semi-structured focus groups or individual interviews. Discussions were recorded and transcribed. Two investigators individually analyzed data for themes using inductive and deductive content analysis aided by NVivo software, four researchers reached consensus on the themes. RESULTS: Eleven women participated, mean age 61 years (range 39-88). Themes and illustrative quotations are listed in the table. Women discussed barriers related to undergoing surgical intervention for SUI, such as embarrassment associated with discussing SUI symptoms, encountering physicians who were not empathetic, and personally needing to advocate for themselves for appropriate referrals. Women recounted specific urinary leakage events that led to their decision to pursue surgical intervention for SUI. Most women expressed satisfaction with the improvement in SUI specific symptoms, while others associated non-SUI symptoms with their surgical outcomes, such as changes in bowel habits and urinary frequency. Despite not having complications related to MUS surgery, some women recounted higher than expected post-operative pain levels and surprise by the ability to palpate the sling vaginally. CONCLUSIONS: Women experienced barriers to SUI care and attributed de novo non-SUI symptoms to their MUS surgery. Appreciating patients’ knowledge, concerns, and expectations regarding SUI can inform FPMRS surgeons on how to better meet patient needs and improve patient understanding when discussing MUS surgery. Listening to understand women's perspectives can improve the informed consent process and surgical counseling for MUS surgery. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e333-e333 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pansy Uberoi More articles by this author Wai Lee More articles by this author Kathleen Kobashi More articles by this author Alvaro Lucioni More articles by this author Donna Berry More articles by this author Una Lee More articles by this author Expand All Advertisement Loading ...

Narrow Vagina as a Predictor of Obstructive Voiding Dysfunction after Transobturator Sling Surgery

Background: Voiding dysfunction (VD) is a potential complication after female midurethral sling operations. Objectives: Our goal was to assess the rate of obstructive VD after ­transobturator tension-free tape (TOT) procedures and to find perioperative risk factors (RFs) predicting postoperative voiding problems. Methods: We have retrospectively evaluated the perioperative data of 397 women who underwent TOT operations. Significant post-void residual (PVR) (>50 mL) was considered as the primary (objective) end point of the study, the voiding difficulty as the secondary (subjective) 1. First univariate analysis and then multivariate logistic regression were performed, with a 5% significance level. Results: Significant PVR was present in 51 (12.8%) women; catheterization was needed in 21 (5.3%) and reoperation in 3 (0.8%) cases. Seventy women (17.6%) experienced postoperative voiding difficulty. Narrow vagina (<2 cm), older age >70 years, and preoperative voiding difficulty were independent RFs for significant PVR (odds ratio: 5.07, 2.14, 5.38, respectively, p < 0.05). Preoperative overactive bladder syndrome and previous pelvic organ prolapse surgery were considered independent RFs for postoperative voiding difficulty. Conclusions: Older age, narrow vagina, or preoperative voiding difficulty increases the chance for significant postoperative PVR. These patients should be chosen and counseled appropriately.

Comparison of Prolift, Perigee-Apogee, Prosima, and Elevate transvaginal mesh systems in pelvic organ prolapse surgery: Clinical outcomes of a long-term observational study.

To evaluate and compare the long-term clinical outcomes of four different transvaginal mesh systems. This retrospective study included 695 patients classified into four groups (Prolift, n=132; Perigee-Apogee, n=186; Prosima, n=60; Elevate; n=317), with a median follow-up time of 5.8 years (range 0.5-12.2 years). The outcomes were objective anatomic success (Pelvic Organ Prolapse [POP] Quantification system stage ≤1), mesh exposure, and urologic functional assessments. For anatomic outcomes, we stepwise analyzed the short-term (within 3 years) and long-term (after 3 years) results. Prolift had the highest long-term success rate (9 years: 82.1%, P= .007). Elevate had a comparable short-term success rate (3 years: 87.5%), but its long-term success rate significantly decreased over time (5 years: 78.6%, 9 years: 66.8%, P= .007). Prosima had the lowest short-term success rate (P= .027). For the long-term mesh exposure rate (9-year cumulative), Elevate had the lowest with 11.1%; next were Perigee-Apogee (18.8%) and Prolift (24.6%); and Prosima had the highest with 39.4%, with a significant difference. In terms of urinary functional results, we observed no significant differences in voiding dysfunction, de novo stress urinary incontinence, or de novo overactive bladder symptoms among the four mesh groups, whether combined with midurethral sling surgery or not. Different vaginal mesh designs have various advantages and features. Prolift provided the best long-term anatomic success but had a high mesh exposure rate. Elevate gave comparable short-term success but had a decreased long-term success rate. However, Elevate is superior with the lowest long-term mesh exposure rate. Prosima had the worst anatomic correction and highest mesh exposure rates. This study provides a comprehensive long-term comparative result for POP patients and surgeons.

Evaluation of Female Patient Satisfaction after Midurethral Sling Surgery for Stress Urinary Incontinence

Background: Stress Urinary incontinence (SUI) is a public health condition that affects women worldwide, Patient satisfaction after stress incontinence surgery is influenced by many factors, patient-specific expectations, postoperative continence status, and complications. Traditionally treatment success has been defined by cure rate and symptom improvement, patient-reported outcomes, particularly satisfaction, have been recognized as complementary measures of success, This study amid to evaluate patient satisfaction post sling surgery for stress urinary incontinence. Methods: It is a retrospective study including 30 female patients, 15 underwent Transobturator Vaginal Tape (TOT) operation and 15 underwent Tension-free vaginal tape (TVT) for stress urinary incontinence between Jan 2019 to Jan 2020 in Urology Department, Faculty of Medicine, Zagazig University. Patients were evaluated 12 month post MUS for complications and satisfactions by(ICIQ-SF) score, quality of life score , female sexual function index, and Global response assessment scale.Results: Marked improvement in International consultation on incontinence Questionnaire –Short Form and quality of life (ICIQ-SF) score dropped from (12.20±2.27) to (1.40±0.51) TOT group and from (11.26±2.15) to (1.06±0.23) in TVT group. The Quality of life score improved by dropping from (5.26±1.22) to (0.48±0.11) and from (5.06±1.09) to (0.51±0.11) in TVT group with no significant difference between both groups. All items of (FSFI) score were improved from pre to post-management without difference between both groups. Conclusions: Mid urethral slings have high patient satisfaction rates regarding the improvements in ICIQ-SF scores and FSFI on short-term and are relatively safe procedures

The Impact of Surgical Center Volume on Reoperation Risk after Mid Urethral Sling.

We sought to determine whether a center's surgical volume affects patient reoperation rates after mid urethral sling (MUS) surgery. We performed a retrospective cohort study evaluating a large managed care organization from 2005 to 2016. The primary outcome was the MUS reoperation rate. Perioperative factors and reoperation of patients were compared using Wilcoxon rank-sum for continuous variables and chi-square for categorical variables. We estimated the adjusted hazard ratio and the 95% confidence interval of reoperation using Cox proportional hazards model. Within the managed care system, 13,404 primary MUSs were performed at 11 centers over the study period (19/105 center years were considered low volume). Higher-volume centers (>58 procedures/year based on concentration curve) performed 93% of surgeries in this cohort. Overall reoperation risk for patients of higher-volume centers was smaller than those of lower-volume centers, 4.9% vs 9.8% at 9 years (hazard ratio 0.45 [p <0.01]). Risk of reoperation for recurrent stress urinary incontinence (SUI) for patients was lower in the higher-volume centers, 4% vs 9.1% at 9 years (p <0.01). Patient of higher-volume centers were less likely to have a reoperation for mesh exposure 0.2% vs 0.7% (p <0.01) or infection 0% vs 0.2% (p <0.01). Patients who had their MUS surgery at a higher-volume medical center were less likely to have any reoperation including for recurrent SUI, mesh exposure or infection. These findings persisted even when controlling for potential covariates including patient demographics and surgeon volume and specialty.

Association between the urogenital microbiome and surgical treatment response in women undergoing midurethral sling operation for mixed urinary incontinence

The urogenital microbiome is associated with urgency and mixed urinary incontinence symptoms and differential treatment responses to pharmacotherapy for urgency urinary incontinence. This study aimed to describe whether the preoperative urinary and vaginal microbiomes were associated with surgical treatment responses at 12 months after a midurethral sling operation in women with mixed urinary incontinence. This cohort study compared the preoperative microbiome compositions of urine and vaginal samples from a subset of women undergoing a midurethral sling operation in the Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence trial (NCT01959347) and compared the microbiota in women who were surgical responders vs surgical nonresponders. Twelve-month objective response was defined as a ≥70% reduction from baseline urinary incontinence episodes on a 3-day diary. Subjective response was defined as a change from baseline in the Urogenital Distress Inventory scores. Bacterial abundance and beta diversity were assessed using 16S ribosomal RNA sequencing. The primary differential abundance analysis described predominant bacterial operational taxonomic units associated with responders vs nonresponders using unadjusted and age-adjusted linear models. Objective nonresponders (n=28) compared with responders (n=72) were older (58.5±10.7 vs 51.6±10.2 years) and more likely postmenopausal without hormone use (odds ratio, 6.4; 95% confidence interval, 1.8-22.6). Vaginal and urinary microbiota beta diversities were associated with age (P<.05) for both responders and nonresponders. Overall, predominant operational taxonomic units (genera) were Lactobacillus, Gardnerella, Tepidimonas, Escherichia, Streptococcus, and Prevotella. Operational taxonomic units from baseline urine samples were not significantly associated (P threshold=.05) with surgical treatment responses. A greater abundance of baseline vaginal Lactobacillus was associated with an objective response (P=.04) and Prevotella with an objective nonresponse (P=.01). Adjusting for age, only a greater abundance of baseline vaginal Prevotella was associated with an objective nonresponse (P=.01). Moreover, less abundant vaginal operational taxonomic units were associated with objective and subjective responses and persistent urinary incontinence symptoms (P<.05). Women meeting a 70% reduction of urinary incontinence treatment episodes (objective responders) had greater vaginal Lactobacillus at the time of the surgical procedure; however, controlling for age diminished this association. Women not meeting a 70% reduction of urinary incontinence episodes 1 year after a midurethral sling operation had greater vaginal Prevotella at the time of the midurethral sling operation. Further research is needed to determine whether therapy altering the vaginal microbiome may impact surgical treatment responses in women with mixed urinary incontinence.

Cost-effectiveness of behavioral and pelvic floor muscle therapy combined with midurethral sling surgery vs surgery alone among women with mixed urinary incontinence: results of the Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence randomized trial

Urinary incontinence is prevalent among women, and it has a substantial economic impact. Mixed urinary incontinence, with both stress and urgency urinary incontinence symptoms, has a greater adverse impact on quality of life and is more complex to treat than either stress or urgency urinary incontinence alone. Studies evaluating the cost-effectiveness of treating both the stress and urgency urinary incontinence components simultaneously are lacking. Cost-effectiveness was assessed between perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery and midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. The impact of baseline severe urgency urinary incontinence symptoms on cost-effectiveness was assessed. This prospective economic evaluation was performed concurrently with the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence randomized trial that was conducted from October 2013 to April 2016. Participants included 480 women with moderate-to-severe stress and urgency urinary incontinence symptoms and at least 1 stress urinary incontinence episode and 1 urgency urinary incontinence episode on a 3-day bladder diary. The primary within-trial analysis was from the healthcare sector and societal perspectives, with a 1-year time horizon. Costs were in 2019 US dollars. Effectiveness was measured in quality-adjusted life-years and reductions in urinary incontinence episodes per day. Incremental cost-effectiveness ratios of combined treatment vs midurethral sling surgery alone were calculated, and cost-effectiveness acceptability curves were generated. Analysis was performed for the overall study population and subgroup of women with Urogenital Distress Inventory irritative scores of ≥50th percentile. The costs for combined treatment were higher than the cost for midurethral sling surgery alone from both the healthcare sector perspective ($5100 [95% confidence interval, $5000-$5190] vs $4470 [95% confidence interval, $4330-$4620]; P<.01) and the societal perspective ($9260 [95% confidence interval, $8590-$9940] vs $8090 [95% confidence interval, $7630-$8560]; P<.01). There was no difference between combined treatment and midurethral sling surgery alone in quality-adjusted life-years (0.87 [95% confidence interval, 0.86-0.89] vs 0.87 [95% confidence interval, 0.86-0.89]; P=.90) or mean reduction in urinary incontinence episodes per day (-4.76 [95% confidence interval,-4.51 to 5.00] vs-4.50 [95% confidence interval,-4.25 to 4.75]; P=.13). When evaluating the overall study population, from both the healthcare sector and societal perspectives, midurethral sling surgery alone was superior to combined treatment. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone is ≤28% from the healthcare sector and ≤19% from the societal perspectives for a willingness-to-pay value of ≤$150,000 per quality-adjusted life-years. For women with baseline Urogenital Distress Inventory irritative scores of ≥50th percentile, combined treatment was cost-effective compared with midurethral sling surgery alone from both the healthcare sector and societal perspectives. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone for this subgroup is ≥90% from both the healthcare sector and societal perspectives, at a willingness-to-pay value of ≥$150,000 per quality-adjusted life-years. Overall, perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery was not cost-effective compared with midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. However, combined treatment was of good value compared with midurethral sling surgery alone for women with baseline severe urgency urinary incontinence symptoms.

Vaginally Assisted Laparoscopic Urethrolysis and Mesh Excision after Tension-free Vaginal Tape

To present technique of vaginally assisted laparoscopic urethrolysis and mesh excision after tension-free vaginal tape. Demonstration video. Despite the Food and Drug Administration's warning to limit the use of mesh, midurethral sling surgery (MUS) has not significantly decreased, but operations for complications have increased 3 times [1]. Urethral obstruction after MUS has an incidence of 2.7% to 11% [2] that requires resurgery, which ranges from pull-down, mesh excision to urethrolysis and is chosen by the surgeon's experience. Retropubic urethrolysis and mesh excision are reported to be more successful [3]. Urethrolysis can be performed by a retropubic, transvaginal, or suprameatal approach. Transvaginal mesh excision and urethrolysis are not satisfactory in all cases, and it might be difficult to identify the mesh if it is dislocated proximally or buried in dense fibrosis, which may increase urethral/bladder injuries. Although vaginal urethrolysis and mesh removal are usually preferred as the primary approach, there is no randomized controlled trial comparing retropubic and vaginal urethrolysis with/without mesh removal. Gynecologists should master each technique to provide individualized treatment. Laparoscopic urethrolysis has the advantage of the identification of neighboring structures and provides a safer operation (Fig. 1). Combined vaginal and laparoscopic approaches can be used to totally remove the mesh and for difficult surgeries at the junction of the retropubic urethra and the midurethra (Fig. 2). (1) Timing of urethrolysis is controversial. Although urethral loosening or pulling down in the first few days and mesh excision in the first 15 days can be useful, urethrolysis can be chosen for delayed cases with marked fibrosis. Preoperative diagnostic cystoscopy to exclude urethral mesh erosion is essential. Intermittent catheterization until surgery should be done. (2) The technique is described in 5 steps. The arcus tendineus is an important landmark [4] (Fig. 3). Laparoscopic urethrolysis for urinary obstruction after MUS can be a safe and successful procedure after failed vaginal approach or can be considered as a primary approach in select cases.

Immunohistochemical Investigation of Autonomic and Sensory Innervation of Anterior Vaginal Wall Female Periurethral Tissue: A Study of the Surgical Field of Mid-Urethral Sling Surgery Using Cadaveric Simulation

Female sexual dysfunction, including female orgasm disorder, has been reported following mid-urethral sling (MUS) surgery to treat bothersome stress urinary incontinence. Anterior vaginal wall-female periurethral tissue (AVW-FPT) likely contains autonomic and sensory innervation involved in the female sexual response, and injury to these nerves may result from MUS implantation. To characterize, using fresh cadaveric tissue, autonomic and sensory nerves in AVW- FPT using immunohistochemistry (IHC), and to assess their proximity to an implanted MUS. AVW-FPT was excised following careful dissection from four fresh cadavers. Prior to dissection, one cadaver underwent simulation of the MUS procedure by a urogynegologist, using a fascial sling. All samples were paraffin embedded, sectioned, and stained with hematoxylin. Serial sectioning and IHC were performed to identify nerves. IHC markers were used to characterize the sensory and autonomic innervation. IHC localization of autonomic and sensory nerve markers consistent with neural tissue within the region of MUS implantation. IHC of AVW-FPT using protein gene product 9.5 (PGP9.5), a general nerve stain, revealed innervation throughout the region targeted by the MUS implantation. More specifically, immunoreactivity for both autonomic (tyrosine hydroxylase, TH) and sensory (Nav1.8 and S100ß) nerves were found in close proximity (<1 mm) to the implanted MUS. In addition, a subset of S100ß positive nerves also showed immunoreactivity for calcitonin gene-related peptide (CGRP). Combining the IHC findings with the surgical simulation of the MUS implantation revealed the potential for damage to both autonomic and sensory nerves as a direct result of the MUS procedure. The identified autonomic and sensory nerves of the AVW-FPT may contribute to the female sexual response, and yet are potentially negatively impacted by MUS procedures. Given that surgeries performed on male genital tissue, including the prostate, may cause sexual dysfunction secondary to nerve damage, and that urologists routinely provide informed consent regarding this possibility, urogynaecologists are encouraged to obtain appropriate informed consent from prospective patients undergoing the MUS procedure. This is the first study to characterize the sensory and autonomic innervation within the surgical field of MUS implantation and demonstrate its relationship to an implanted MUS. The small sample size is a limitation of this study. The present study provides evidence of potential injury to autonomic and sensory innervation of AVW-FPT as a consequence of MUS implantation, which may help explain the underlying mechanisms involved in the reported post-operative female sexual dysfunction in some women.